Electroacupuncture for Pain Outcomes in a Trauma Center's Acute Pain Service: A Retrospective Observational Study

Abstract

Background:

Evidence for acupuncture to treat pain is growing. Electrostimulation of acupuncture needles (electroacupuncture) is common for pain and is thought to augment the therapeutic effect.

Objectives:

To examine the association of pain outcomes after a single acupuncture session with electrostimulation included (EA) compared with no electrostimulation included (NEA).

Methods:

A retrospective observational study was conducted using electronic health records of acupuncture sessions for adults with acute pain under the care of an acute pain service. Paired t-test and linear regression were used to report pain intensity changes after a single acupuncture session and by including EA. Ordered logistic regression was used to report categorical pain relief. Logistic regression was used to explore the odds of adding EA and the patient's age, gender, and pretreatment pain.

Results:

From July 24, 2017, through November 9, 2020, 465 acupuncture sessions recorded EA (n = 194), or NEA (n = 271). Acupuncture, independent of EA status, reduced pain intensity by a mean 2.5 points. EA was associated with a mean 0.38-point reduction in pain intensity more than NEA (confidence interval [95% CI]: −0.75 to −0.01). Among sessions reporting categorical pain relief (n = 415), higher relief was more likely with EA (odds ratio = 2.16, 95% CI: 1.52–3.08). There was no association between EA and the patient's age, gender, and pretreatment pain intensity.

Conclusions:

After a single acupuncture session, both EA and NEA reduced pain intensity. Higher categorical pain relief was reported with EA, though the clinical meaning is uncertain. Future research should focus on well-defined populations for electroacupuncture and factors for including electrostimulation.

INTRODUCTION

Acute pain services (APSs) and other pain centers provide management for patients requiring high-level multimodal and multidisciplinary approaches to surgery-related pain and other complex pain conditions.^1–3 Over 28 million surgeries occur in hospital settings in the United States annually.⁴ A majority of these patients experience significant postoperative pain.¹ A significant number of nonsurgical patients also experience acute pain during hospitalization.⁵ Despite the many methods for pain control, inadequate pain relief remains a significant issue.^1,6–9

Acupuncture is a potentially helpful treatment to manage many pain conditions. Systematic reviews have reported beneficial effects of acupuncture for musculoskeletal and postoperative conditions.^10–12 Research also supports the use of acupuncture to decrease pain intensity and opioid consumption among patients in both an emergency department and postoperative setting.^10,12–14 Other studies support the use of acupuncture in hospital settings for acute pain from trauma and nontrauma conditions.^15–18 A series of acupuncture treatments over several weeks is typically recommended for chronic pain.¹⁹ However, most acupuncture consumers in the United States receive a suboptimal dose with only a few treatments.^20,21

Acupuncture needle stimulation is often applied by hand (manual stimulation) and by using electricity with a small device that is adjustable for frequency, intensity, and amperage (electroacupuncture or electrostimulation).^22,23 Studies examining the direct comparison in treatment effects between manual and electrical needle stimulation are limited and offer mixed results. Electrostimulation has been shown to exert a quicker and stronger effect on single electrical pain thresholds and for temporal summation than manual stimulation, though the clinical impact is unclear.²⁴

The Society for Acupuncture Research in a series of white papers notes it being common to assume that the use of electrical stimulation on the acupuncture needle is interchangeable with manual stimulation but that electrical stimulation may provide a more potent treatment.²²

There are currently no uniform clinical guidelines to direct a practitioner's choice to include electrostimulation. Sherman et al. found that practitioners commonly employ electrostimulation because the patient was felt to need it, there were no therapeutic results with more basic methods, the patient requested it, or its use removed the necessity of conducting manual stimulation.²⁵ Moreover, not only it is common in practice to combine both methods in the same acupuncture session, but it is also common for acupuncture needles to be inserted and retained with no stimulation.

The purpose of this study was to examine the effects of including electrostimulation in a single acupuncture session on post-treatment pain intensity and pain relief among patients in an APS hospitalized at a level 1 trauma center. Specifically, it was aimed to (1) examine differences in self-reported pain intensity after a single acupuncture session with electrostimulation included (EA) compared with acupuncture sessions with no electrostimulation included (NEA), (2) examine differences in self-reported categorical pain relief ratings after a single acupuncture session between EA compared with NEA, and (3) to explore whether the use of EA compared with NEA differed by the patient's gender, age, and pretreatment pain intensity.

METHODS

Study Design

A retrospective observational study was conducted of acupuncture sessions provided to adult patients with acute pain under the care of an APS. The acupuncture sessions for patients with an acupuncture form in the care of the APS from July 24, 2017, to November 9, 2020, were identified through an electronic health records query. The University of Washington Institutional Review Board determined that this study does not involve human subjects as defined by federal and state regulations.

Study Population

Acupuncture was provided to a convenience sample of hospitalized adult patients under the care of an APS for complex acute pain and pain-related conditions from surgical and nonsurgical procedures or multimodal treatment plans for pain management at a 413-bed tertiary care hospital and level 1 adult and pediatric trauma and burn center for the Pacific Northwest region. The program to include integrated acupuncture in the APS has been described elsewhere.²⁶ All patients with APS consultations were acupuncture candidates unless there was a contraindication (e.g., therapeutic anticoagulation, absolute neutrophil count under 500, implanted defibrillator or vagal nerve stimulators, untreated bacteremia, pregnancy, or acute decompensating conditions).

Acupuncture was provided as an adjunct therapy, and other therapies offered included various combinations of physical methods such as physical or occupational therapy, opioids and nonopioid adjuvants, specialized pain management techniques such as continuous peripheral and epidural analgesia, and other nonpharmacologic care such as rehabilitation psychology, spiritual care, and distraction methods.

Acupuncture Sessions

Patients provided formal written consent for each acupuncture session. Some patients requested acupuncture based on prior knowledge of the service or on prior acupuncture experience. Approximately 2 acupuncturists per shift provided treatment, and the number of acupuncturists enrolled per year varied significantly.

Acupuncture occurred in the patient's hospital room and followed an individualized acupuncture point prescription rather than a prespecified protocol. The treating acupuncturist collected the patient-reported pain intensity and pain relief scores during the acupuncture session, and recorded the time the acupuncture encounter began and ended. Clinical reasoning for the determination to employ electrostimulation was multifaceted, including the practitioner's clinical expertise, preference for this method, and knowledge of the patient including an evaluation of medical contraindications.

Because of this, the treatments varied in the types of acupuncture points (auricular, body, or scalp), needle type, the number of needles, retention time, depth of insertion, and whether the practitioner chose to elicit or not elicit de qi. In addition, patients might have received acupuncture >1 time and also for different complaints during the same hospitalization.

Study Sample

The authors restricted the study sample to acupuncture sessions for adults 18 years of age and older that recorded the acupuncture treatment details and whether electrostimulation was included. Sessions that did not record both pre-treatment and post-treatment pain intensity scores were excluded. Aim 2 also employed a complete case approach in which records missing a categorical response to the pain relief scale (PRS) were also excluded.

Identification of EA

The exposure was acupuncture sessions that recorded the inclusion of electrostimulation as documented by the acupuncturist (EA group). The comparison group was acupuncture sessions that did not record the inclusion of electrostimulation (NEA group). In both study groups, all acupuncture points with no electrostimulation could have included either manual needle stimulation or needle insertion and retention with no needle stimulation.

Outcomes

Change in Pain Intensity After a Single Acupuncture Session

The primary outcome was the change in self-reported pain intensity from pre- to post-treatment after a single acupuncture session, using a numeric rating scale (NRS)²⁷ of 0 (no pain) to 10 (worst pain possible). Patients reported their pain intensity immediately before and after the acupuncture session. The change in pain intensity was calculated by taking the difference of these 2 scores. Pre-treatment pain scores were subtracted from post-treatment pain scores so that a negative value reflects a reduction in pain intensity and a positive value reflects an increase in pain intensity. A difference of 2 points on the pain NRS is considered clinically meaningful.^28,29

Pain Relief After a Single Acupuncture Session

The patient self-reported pain relief was investigated after a single acupuncture session with the categorical PRS,³⁰ a method that measures the magnitude of change in pain intensity after treatment. Using this scale, the patients rated their pain relief with 5 ranked categories (“none,” “slight,” “moderate,” “lots,” and “complete”). A response from the patient of “moderate” relief is considered clinically meaningful and correlates with a 1- to 2-point change in the verbal analog scale using a range of 0–10.³¹

Factors Associated with the Use of Electrostimulation

The use of EA as the outcome to investigate the acupuncturist's inclusion of electrostimulation was explored based on the covariates of interest.

Covariates

A patient's gender, age, and pre-treatment pain intensity were considered as possible confounding variables. Gender was recorded as a binary, male or female. Age in years at the time of the acupuncture session was recorded as a continuous variable. Pre-treatment self-reported pain intensity was reported using the NRS of 0 (no pain) to 10 (worst pain possible).

Analysis

Descriptive statistics was used to characterize the study sample, and also to characterize the acupuncture session details for adding electrostimulation, time duration of the acupuncture session, pre-treatment pain intensity, post-treatment pain intensity, difference in pain intensity from pre-treatment to post-treatment, and post-treatment pain relief. The mean and standard deviation for continuous variables were calculated and categorical variables were presented by their group frequency and percent.

A paired t-test was used to examine the mean difference in pain intensity from a single acupuncture session, pre- to post-treatment, among all acupuncture sessions regardless of electrostimulation status. For the primary aim, a linear regression model was then fit to assess the outcome of pain intensity change from a single acupuncture session, comparing the EA group with the NEA group. Patient's age and gender were included as covariates in the model.

Aim 2 used ordered logistic regression to examine the secondary outcome of categorical pain relief by including EA in a single acupuncture session. This model adjusted for the patient's age and gender.

Aim 3 used a multivariate logistic regression model with the use of EA as the outcome to investigate the acupuncturist's inclusion of electrostimulation based on the patient's age, gender, and pre-treatment pain intensity.

Robust standard error estimates were reported for all regression models. A value of P < 0.05 was considered statistically significant. R statistical software version 4.0.3 was used.³²

RESULTS

Study Sample Characteristics

Figure 1 displays the study flow. From July 24, 2017, through November 9, 2020, 548 acupuncture sessions were identified. In total, 83 acupuncture sessions that did not record pre- or post-treatment pain intensity scores were excluded. This process left 465 acupuncture sessions for the study sample (Table 1). One-hundred ninety-four (41.7%) acupuncture sessions included electrostimulation and were in the EA group, and 271 (58.3%) acupuncture sessions did not include electrostimulation and were in the NEA group. The treatment groups were similar in age, but only 34.5% of the EA group identified as female compared with 42.8% of the NEA group. The EA group had a mean treatment time of 1.6 minutes more than the NEA group.

FIG. 1.

Study flow.

Table 1.

Characteristics of Acupuncture Sessions (N = 465)

	EA (n = 194)	NEA (n = 271)
Age, mean (SD)	44.7 (13.8)	47.4 (15.3)
Female, n (%)	67 (34.5)	116 (42.8)
Treatment time,^a mean (SD)	38.1 (17.6)	36.5 (47.5)
0–15 minutes, n (%)	2 (1.0)	6 (2.2)
16–30 minutes, n (%)	79 (40.7)	132 (48.7)
31–45 minutes, n (%)	66 (34.0)	80 (29.5)
46–60 minutes, n (%)	38 (19.6)	29 (10.7)
61–75 minutes, n (%)	1 (0.5)	3 (1.1)
More than 75 minutes, n (%)	1 (0.5)	4 (1.5)
Missing, n (%)	7 (3.6)	17 (6.3)
Pain intensity^b
Pre-treatment, mean (SD)	6.5 (2.2)	6.7 (2.2)
Post-treatment, mean (SD)	3.7 (2.5)	4.3 (2.6)
Change in pain intensity,^c mean (SD)	−2.7 (2.0)	−2.4 (2.1)
Pain relief^d
None, n (%)	7 (3.6)	30 (11.1)
Slight, n (%)	41 (21.1)	88 (32.5)
Moderate, n (%)	60 (30.9)	75 (27.7)
Lots, n (%)	44 (22.7)	46 (17.0)
Complete, n (%)	15 (7.7)	9 (3.3)
Missing, n (%)	27 (13.9)	23 (8.5)

Treatment times shown are for the total acupuncture session and can include multiple rounds of needle insertion and removal, and does not necessarily indicate the length of time for needle retention or electrostimulation.

Pain intensity recorded from 0 to 10 with a numeric rating scale.

Negative values reflect a reduction in pain intensity and positive values reflect an increase in pain intensity.

Pain relief scored with the Pain Relief Scale.

EA, electrostimulation included in the acupuncture session; NEA, no electrostimulation included in the acupuncture session; SD, standard deviation.

Pain Intensity

From a single acupuncture session, independent of electrostimulation status, the mean reduction in pain intensity pre- to post-treatment was 2.5 (±2.1) points and ranged from a reduction of 10 points to an increase of 2 points. This change was considered statistically significant (paired t-test, P < 0.001). For the 2 study groups, the mean reduction in pain intensity for the EA group was 2.7 points, and for the NEA group the mean reduction in pain intensity was 2.4 points. When comparing single acupuncture sessions in the EA group with that of the NEA group, the covariate-adjusted pain intensity change from a single acupuncture session in the EA group was on average a reduction of 0.38 points more (confidence interval [95% CI]: −0.75 to −0.01) (Table 2). These results were considered statistically significant (P = 0.04).

Table 2.

Linear Regression for Changes in Preacupuncture to Postacupuncture Pain Intensity (N = 465)

	Estimate	SE	95% CI	P
Electrostimulation	−0.38	0.19	−0.75 to −0.01	0.04
Gender (male)	0.55	0.20	0.15 to 0.94	0.01
Age (years)	0.00	0.01	−0.01 to 0.02	0.82

Pain intensity recorded from 0 to 10 with a numeric rating scale. For changes in pain intensity, preacupuncture to postacupuncture, a negative value reflects a reduction in pain intensity and a positive value reflects an increase in pain intensity.

CI, confidence interval; SE, standard error of the estimate.

Pain Relief

PRS scores were missing in 50 acupuncture sessions (10.8%). Of the 415 acupuncture sessions recording PRS scores, a majority (60.0%) reported at least moderate pain relief or more after a single acupuncture session, independent of electrostimulation status. Most acupuncture sessions recorded at least moderate pain relief after a single acupuncture session in both acupuncture groups (71.3% EA group, 52.4% NEA group).

When comparing single acupuncture sessions in the EA group with that in the NEA group, the covariate-adjusted categorical PRS in the acupuncture sessions in the EA group was more likely to report a higher category of pain relief (odds ratio [OR] = 2.16, 95% CI: 1.52–3.08) (Table 3).

Table 3.

Ordered Logistic Regression for Post-Treatment Categorical Pain Relief (N = 415)

	OR	95% CI	P
Electrostimulation	2.16	1.52–3.08	<0.001
Gender (male)	0.74	0.52–1.07	0.11
Age (years)	0.98	0.97–0.99	<0.01

Pain relief recorded postacupuncture with the Pain Relief Scale and categorized as “none,” “slight,” “moderate,” “lots,” or “complete.”

CI, confidence interval; OR, odds ratio.

Factors Associated with the Use of Electrostimulation

In the multivariate logistic regression model, the EA group, compared with the NEA group, did not differ significantly by pre-treatment pain intensity, age, or gender (Table 4).

Table 4.

Predictors for Including Electrostimulation (N = 465)

	OR	95% CI	P
Preacupuncture pain intensity	0.96	0.88–1.05	0.41
Gender (male)	1.32	0.89–1.95	0.17
Age (years)	0.99	0.98–1.00	0.10

CI, confidence interval; OR, odds ratio.

DISCUSSION

The results of this observational study demonstrate that acupuncture provides a clinically meaningful reduction in pain intensity and pain relief for hospitalized patients with acute pain. Electroacupuncture is commonly used in this setting, and acupuncture augmented with electrostimulation provides similar analgesia to acupuncture without electrostimulation.

Among all acupuncture sessions, the mean reduction from a single acupuncture session in pre- to post-acupuncture session pain intensity of 2.5 points on an 11-point NRS is both statistically significant and clinically meaningful. However, even with the odds of reporting a higher categorical pain relief being greater with employing electrostimulation, including electrostimulation only decreased numeric pain intensity scores by 0.38 points more compared with acupuncture sessions with no electrostimulation added. In addition, the findings for categorical pain relief should be interpreted with caution, given the wide CIs obtained with the calculated OR.

This overall reduction in pain intensity of 2.5 points independent of including electrostimulation is in line with existing literature for acupuncture when pain intensity is measured using analog pain scales.^33–38 However, there was only a slight reduction in pain intensity after treatment in the EA group compared with that in the NEA group, and current research on the effects of electrostimulation on pain intensity is inconsistent. A recent meta-analysis found that electroacupuncture reduced pain intensity by an estimated standard mean difference of 1.6 among individuals 24 hours post-thoracotomy.³⁹

Another meta-analysis found electroacupuncture reduced pain intensity by less than a single point compared with a control group on days 3 and 7 post-total knee arthroplasty.⁴⁰ However, other individual studies reported no differences between the 2 needle stimulations,^41–43 whereas others found electrostimulation superior to manual acupuncture for pain intensity.^44–48 Moreover, these studies and others about needle stimulation methods focused on specific clinical populations,^39–49 followed prespecified acupuncture point protocols,^43,45–49 restricted acupuncture points to either the ear^45–47,49 or to conventional body acupuncture points,^43,48 allowed for multiple acupuncture treatments,^43–46 or administered acupuncture perioperatively.⁴⁷

The heterogeneity of the existing literature thus limits the ability to make meaningful comparisons about the association of adding electrostimulation and pain outcomes, as this study only allowed for examination based on a single acupuncture session among patients with diverse clinical presentations.

The results indicate that pre-treatment pain intensity, age, and gender were not associated with electrostimulation status. As such, the results restrict the ability to further characterize what specific factors might contribute to the decision to employ electroacupuncture. And although the time burden for including acupuncture is low at a mean 1.6 minutes more than not including electroacupuncture, the use of this needle stimulation method has many therapeutic applications that extend beyond pain complaints.²² Congruent with Sherman et al.,²⁵ there remains the need for further research to explore this decision-making process to identify the specific factors involved.

Strengths and Limitations

The strengths of this study include a large sample size, the use of validated patient-reported pain assessment scales, and acupuncture point prescriptions (with and without electrostimulation) that more accurately reflect authentic day-to-day practice. The choices of acupuncture points reflect multiple therapeutic systems, including auricular, scalp, and more conventional body acupuncture.

However, this study has many limitations that restrict the ability to generalize these findings. This study is observational—single acupuncture sessions were analyzed rather than individual patients, and the data were limited in specific details about the acupuncture.

As a retrospective review of the electronic record of APS patients, no randomization occurred to allocate participants to receive electrostimulation. There was no standardization for either the prescription of acupuncture points or the delivery of the acupuncture itself. No protocols existed for including electrostimulation or any other method of needle stimulation. Consequently, specific acupuncture providers might favor electrostimulation over other forms of needle manipulation. There was a lack of a nonacupuncture control group, and no comparison of the needle stimulation with identical acupuncture points. Patients provided consent to every individual acupuncture session and could also decline to have electrostimulation.

There was no masking of data collectors as the treating acupuncturists collected patient-reported pain intensity and relief scores. Therefore, the observational design of this study might not have accounted for important factors associated with the use of electrostimulation and the outcomes of interest, potentially biasing the results. Even so, the results are consistent with the existing literature as already noted for an overall reduction of 2.5 points in pain intensity.

Another limitation of this study is the examination of units of single acupuncture sessions rather than units of individual patients. The patients in this study had acute pain during hospitalization from various surgeries or other complex conditions. The same patient might have been treated more than once for the same complaint during hospitalization. Individual patients might assess their pain outcomes as consistently higher or lower. However, patients possibly had acupuncture for different complaints during the same hospitalization or multiple hospitalizations for the same or different conditions.

As such, an individual patient might have multiple observations in this data set for the same or different complaints. A single stand-alone treatment or even a few spaced-apart treatments might not represent the same effects as regular or daily acupuncture for the same complaint.

A third limitation of this study stems from the limited information in the data itself. Many acupuncture details (e.g., acupuncture style employed or obtaining de qi) as required for an experimental trial in accord with the Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA)⁵⁰ are absent. The time intervals in the data reflect the duration of the entire acupuncture session, inclusive of any single or multiple needle removals and reinsertions. Therefore, information about the specific length of time for applying electrostimulation to acupuncture needles within a single session is absent.

Consequently, any time–dose relationship for pain outcomes based on acupuncture with electrostimulation and no electrostimulation could not be examined. Safety information was also absent from this data set, restricting the ability to report the rate of any complications from using electroacupuncture and other forms of acupuncture. However, this information for this acupuncture program has been reported elsewhere.²⁶ Summarized here, Lumiere et al. indicated that only 7 acupuncture sessions from July 24, 2017, through October 1, 2018, recorded slight bleeding from acupuncture, and 13 sessions recorded early termination of acupuncture because of staff interruption (n = 3), urinary urgency (n = 5), and an otherwise inability for the patient to lie still (n = 5).

Also, due to the heterogeneity of clinical presentations and multiplicity of trauma-related injuries in this sample, outcomes based on the type of medical condition, injury, surgery, or surgery status associated with the pain or control for other forms of analgesic treatments could not be examined. The authors did not have information on the timing of opioid consumption and the administration of acupuncture and how that timing might affect pain outcomes. The authors also had no information on the long-term analgesic effects of acupuncture and its effects on opioid consumption.

CONCLUSIONS

A single acupuncture session reduced pain in patients hospitalized with complex acute pain conditions independent of electrostimulation. The evidence suggests that including electrostimulation may be associated with higher categorical pain relief than not including electrostimulation. However, in this patient population, comparing acupuncture sessions with and without electrostimulation, acupuncture that included electrostimulation reduced pain intensity by only an additional 0.38 points on an 11-point scale, which is not considered clinically meaningful.

Future research should focus on well-defined patient populations, including specific complaints and surgery types, to determine the most appropriate medical conditions for electrostimulation, including the optimal frequency, intensity, and amperage used. In addition, rigorously designed studies should examine any cumulative effects of multiple acupuncture treatments. Future research should also examine patient characteristics to determine factors associated with improved pain outcomes from adding electrostimulation. Finally, future research should also address clinician and patient preferences for adding electrostimulation to the treatment to determine whether this might affect patient use of acupuncture for complex pain conditions.

Footnotes

ACKNOWLEDGMENTS

The authors thank Harborview Medical Center, Bastyr University, and University of Washington School of Medicine for their support of this study.

AUTHORs' CONTRIBUTIONS

M.D.S. contributed to conceptualization, data curation, formal analysis, methodology, software, visualization, and writing. E.L.G. was involved in formal analysis, methodology, and writing. C.M., S.B., and K.L. carried out conceptualization and writing. M.S.V. was involved in supervision and writing. D.B.G. was in charge of conceptualization, supervision, and writing.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Centers for Disease Control and Prevention.

AUTHOR DISCLOSURE STATEMENT

No competing financial interests exist.

FUNDING INFORMATION

This study was supported by the National Institutes of Health under a National Center for Complementary and Integrative Health supplement to the National Center for Advancing Translational Sciences award KL2 TR002317 (MS), and under grants from the National Center for Injury Prevention and Control, 5R49CE003087-03 (MV).

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